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How Africa Subsidizes U.S. Health Care

By Sebastian Mallaby

Monday, November 29, 2004; Page A19

This Wednesday is World AIDS Day: It will be marked by concerts and candlelit vigils from Armenia to Zambia. The speeches and statistics will have a horrific familiarity: Two decades after the first diagnoses, AIDS shows no signs of letting up. And yet the debate about AIDS is changing subtly. In Africa, the epicenter of the crisis, the shortage of cash and affordable medicines is no longer the prime issue. Attention is turning to the shortage of health workers, and hence to a dark aspect of globalization.

It isn't a surprise that Africa is short of doctors and nurses: The continent has 1.4 health workers per 1,000 people, compared with 9.9 per 1,000 in North America. What's shocking is that this shortage is partly created by rich countries. Poor nations such as Malawi and Zambia are paying to train medics who emigrate to staff the hospitals of the United States and Europe. We should be helping Africa. Instead, Africa is subsidizing us.

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Not just slightly, either. Ghana trains 150 doctors annually; five years after graduation, 80 percent have left, according to Ghanaian data reported by the World Bank. For pharmacists, the proportion is about 40 percent; for nurses and midwives, it's about 75 percent -- which is why half the nursing posts in Ghana are vacant. Meanwhile, South African doctors emigrate at a rate of about 1,000 annually. In 2001, Zimbabwe graduated 737 nurses; 437 left for one country, Britain.

Medical migration is not a new phenomenon. Sabina Alkire and Lincoln Chen of Harvard cite the (non-African) example of the Philippines: In 1970 more Filipino nurses were registered in the United States and Canada than in their home country. But the migration is accelerating. In 2001, the number of emigrating Filipino nurses was three times higher than in 1996. Likewise, the number of non-European Union nurses and midwives in Britain has jumped more than tenfold in a decade.

This isn't a scandal; it's more complex than that. Development economists have traditionally celebrated migration as a route out of poverty: If a cab driver moves from Lima, Peru, to Los Angeles, his income whizzes up even though his skills remain the same. Moreover, the immigrant cab driver may send money home to relatives; such remittances to poor countries are twice the size of official development assistance. Harvard's Dani Rodrik calculates that further liberalization of visa rules could benefit the citizens of poor countries more than liberalized access to the rich world's outrageously protected markets for farm goods.

That's the upside of the global labor market. But the downside is equally powerful, and it deserves special consideration given the evolution in our understanding of what it takes for poor countries to grow. The central finding of development economics in the past decade is that institutions matter: You need efficient, uncorrupt government departments and public services to create a foundation for private-sector growth. But how do you create competent institutions if global price signals are sucking your best people out of the country? The medical brain drain is just one example of this problem, which is the central challenge of development in a globalized world.

It's a particularly vivid one, however. After a century of the most spectacular health advances in human history, life expectancy in many poor countries is actually falling. Donors have battled this reversal by making money and medicines available: In Botswana, for example, the pharmaceutical giant Merck has teamed up with the Bill and Melinda Gates Foundation to bring overwhelming resources to bear in the battle against AIDS. But Botswana has made only gradual progress, and a main obstacle has been the shortage of competent administrators and health workers.

It's hard to weigh the issues here: the right of individuals to seek a better life by emigrating and the poverty trap that they entrench by doing so. But it's clear that, in the absence of some kind of intervention, this poverty trap may deepen. The citizens of the rich world are aging; their willingness to care for infirm relatives is waning; medical breakthroughs constantly expand the demand for medical personnel. All these factors reinforce the rich world's temptation to poach the poor world's health workers.

There is no one-shot fix for this problem, but several policies could help. Rich countries should compensate poor ones for the cost of training medics who emigrate; that money, supplemented by other aid flows, should be used to boost medical salaries in the poor world. Poaching countries should issue fewer permanent visas and more temporary ones. Temporary visas spread the opportunity to migrate more broadly, and returnees go home with experience and savings that fuel development.

And then there is another reform that applies specifically to one country. The United States must end its nutty overpayment for health care, which not only wastes billions but also sends price signals that depopulate hospitals in the poor world. Elliott Fisher of Dartmouth Medical School has demonstrated that regions of the United States with a high concentration of medics spend extra on health care without becoming healthier: This country actually has too many health workers. Meanwhile in Africa a single nurse can be responsible for 50 patients. Because of America's dysfunctional system, the global labor market is siphoning doctors from places where they are needed into places where they accomplish nothing measurable at all.